Airway Health Assessment

First Name

Last Name

Have you ever been given a CPAP device?

Yes

If you have been given one, do you use it every night?

Yes

Are you comfortable with your CPAP and satisfied with its use?

Yes

If you answered YES to all three of these questions, you are done. Thank you!

If you answered NO to any of these questions, please continue to Parts 1 and 2.

PART 1: Epworth Sleepiness Scale

On your worst day, how likely are you to doze off while doing the following activities?

Please use this scale: 0= Never, 1= Slight, 2= Moderate, 3= High

Check one of the following numbers:

Being a passenger in a motor vehicle for an hour or more

Sitting and talking to someone

Sitting and reading

Watching TV

Sitting inactive in a public place

Lying down to rest in the afternoon

Sitting quietly after lunch without alcohol

In a car, while stopped for a few minutes in traffic

PART 2:

Have you ever been told you snore?

Yes

Does snoring cause any problems at home?

Yes

If you answered YES, would you like to fix that?

Yes

Do you ever wake up choking and/or gasping?

Yes

Do you have high blood pressure?

Yes

Do you have diabetes?

Yes

Have you ever experienced an irregular heart rhythm?

Yes

Do you feel fully rested upon waking in the morning?

Yes

Height

Weight

Signature of Patient/Legal Guardian

Date

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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